Syringe Services Programs
What are syringe services programs?
Syringe Services Programs (SSPs) provide low-barrier access to sterile supplies for safer substance use, naloxone and overdose prevention tools like fentanyl test strips and drug checking services. SSPs also provide a range of other services, such as options for safe syringe disposal, overdose recognition and response training and help accessing services for HIV, substance use disorders and more.2,3
Community-based SSPs are often led by people with lived experience of substance use who are committed to a harm reduction philosophy and foster a non-judgmental environment for people who are seeking support for their substance use but face discrimination, financial barriers or other challenges when interfacing with other healthcare institutions.2
“High-quality syringe services programs can prevent the spread of disease, save lives, and connect people to other health services, including treatment for substance use disorder.”
–Dr. Rahul Gupta, Director of the Office of National Drug Control Policy1
What evidence supports SSPs as a public health strategy?
The evidence that SSPs prevent overdose is so great that the CDC has endorsed SSPs as one of the most effective, scientifically proven prevention strategies.2
SSPs prevent overdose. SSPs are very effective at providing low barrier access to evidence-based overdose prevention tools, like naloxone4 and fentanyl test strips.5,6 SSPs are also very effective at linking people to medication for opioid use disorder (MOUD), which reduces the risk of overdose.7,8
SSPs link many people to substance use disorder treatment. Studies have found that people who participate in local SSPs are significantly more likely to enter treatment for substance use disorder compared to those who do not.7,9,10 Many SSPs collaborate with healthcare providers to offer MOUD treatment in-person or via telehealth.
SSPs reduce substance use. As many as 4 in 5 SSP participants are interested in reducing or ceasing their substance use.9 SSP participants are more than twice as likely to reduce the frequency of their substance use and more than three times as likely to stop using substances entirely compared to those who do not.10
SSPs prevent disease. Access to sterile supplies significantly reduces the transmission of infectious disease, such as HIV and hepatitis C, and prevents potentially life-threatening bacterial infections causing abscess, endocarditis and sepsis.2
SSPs reduce crime and make neighborhoods safer. SSPs reduce the amount of syringe litter in the neighborhoods where they operate by providing multiple options for safer disposal.11,12 SSPs do not increase or promote criminal activity13,14 and have been linked to crime reduction in cities like San Francisco.15
Are there risks to my community or institution if we don’t support SSPs?
Yes. More fatal overdoses may occur. Though it is possible to obtain naloxone through other means, such as a physician or pharmacy, research is clear that SSPs are the most effective way to distribute naloxone to those most likely to save a life by using it. One study found that pharmacies would have to distribute more than twice as many naloxone kits as community-based SSPs to prevent the same number of overdose fatalities.4
HIV outbreaks may occur. Recent HIV outbreaks in Indiana, Massachusetts and West Virginia have been linked to local policies restricting access to SSPs (such as limited hours, proof of residency requirements, distribution limits or outright SSP bans).16–18 In addition to being a serious public health crisis, HIV outbreaks are expensive: each new case costs more than $350,000 to treat over a single lifetime.19
Fewer people will access treatment for substance use disorders. SSPs are the most effective and well-trafficked pathway to effective treatment for substance use disorders. People who utilize SSP services are many times more likely to begin treatment, stay in treatment and cease substance use than those who do not.7–10
What are some examples of successful SSPs?
The Eastern Band of Cherokee Indians established the Tsalagi Public Health SSP in 2018. In addition to providing access to sterile supplies and naloxone, the SSP has linked nearly 1 in 14 participants to treatment for substance use disorders.34
Sonoran Prevention Works (SPW) is a nonprofit harm reduction organization founded by people who use drugs. In addition to operating three urban service locations, SPW conducts community-informed outreach programs in Arizona’s southern and rural counties. In 2021, SPW trained over 1,000 individuals in harm reduction best practices for overdose prevention and naloxone administration in Cochise, Graham and Santa Cruz counties and distributed nearly 2,500 naloxone kits in these communities.35
Prevention Point Philadelphia is an SSP in Philadelphia’s Kensington neighborhood. In addition to other essential public health services, like access to naloxone and sterile supplies for safer substance use, Prevention Point also offers MOUD treatment onsite.36
The North Carolina Harm Reduction Coalition offers mobile SSP services in several North Carolina counties, expanding access to rural areas of the state where community members face long travel times and other barriers to seeking services often clustered in urban areas.37
These and many other model programs are described online at the Brandeis Opioid Resource Connector
Implementation Guidelines and Best Practices
- National Harm Reduction Coalition’s “Peer Delivered Syringe Exchange (PDSE) Toolkit”
- National Harm Reduction Coalition’s “Establishing a Syringe Services Program in Rural America”
- U.S. Centers for Disease Control and Prevention’s “Syringe Services Program: A Technical Package of Effective Strategies and Approaches for Planning, Design, and Implementation”
- Comer Family Foundation’s “A Guide to Establishing Syringe Services Programs in Rural, At-Risk Areas”
Legal and Legislative Tools
National Harm Reduction Technical Assistance Center (NHRTAC)
The NHRTAC was established by the U.S. Centers for Disease Control and Prevention and the U.S. Substance Abuse and Mental Health Services Administration to provide free assistance to those implementing harm reduction services in their community. Technical assistance for implementing SSPs may be requested through the NHRTAC website.
Rural Health Information Hub (RHIhub)
On its website, RHIhub hosts a toolkit to support community leaders in establishing SSPs, including considerations for program planning, implementation, and evaluation.
National Association of State and Territorial AIDS Directors (NASTAD)
NASTAD provides technical assistance for the implementation of SSPs to health departments and community-based organizations. They also provide regional harm reduction support through a network of professional consultants working across the United States as well as regional SSP technical assistance call series.
Author, Jennifer J. Carroll, PhD, MPH
The two largest opioid settlements include requirements on how funds can be spent. Learn more about approved uses of the funds that are high-impact and under county authority.
Syringe Services Programs (SSPs) provide low-barrier access to sterile supplies for safer substance use, naloxone and overdose prevention tools like fentanyl test strips and drug checking services.
Medication-assisted treatment is considered the “gold standard” of care for opioid use disorder (OUD). The FDA has approved three medications for treating OUD: methadone, buprenorphine and naltrexone.
During pregnancy, the evidence-based standard of care for opioid use disorder (OUD) is treatment with methadone or buprenorphine.
- The White House. White House Releases Model Law to Help States Ensure Access to “Safe, Effective, and Cost-saving” Syringe Services Programs. The White House. Published December 8, 2021. Accessed October 7, 2022. https://www.whitehouse.gov/ondcp/briefing-room/2021/12/08/white-house-releases-model-law-to-help-states-ensure-access-to-safe-effective-and-cost-saving-syringe-services-programs/
- Carroll JJ, Green TC, Noonan RK. Evidence-Based Strategies for Prevention Opioid Overdose: What’s Working in the United States. Published online 2018. Accessed October 10, 2018. http://www.cdc.gov/drugoverdose/pdf/pubs/2018-evidence-based-strategies.pdf
- Carroll JJ, Asher A, Krishnasamy V, Dowell D. Linking People with Opioid Use Disorder to Medication Treatment. Published online 2022. Accessed June 8, 2022. https://www.cdc.gov/drugoverdose/pdf/pubs/Linkage-to-Care_Edited-PDF_508-3-15-2022.pdf
- Irvine MA, Oller D, Boggis J, et al. Estimating naloxone need in the USA across fentanyl, heroin, and prescription opioid epidemics: a modelling study. The Lancet Public Health. 2022;7(3):e210-e218. doi:10.1016/S2468-2667(21)00304-2
- Peiper NC, Clarke SD, Vincent LB, Ciccarone D, Kral AH, Zibbell JE. Fentanyl test strips as an opioid overdose prevention strategy: Findings from a syringe services program in the Southeastern United States. International Journal of Drug Policy. 2019;63:122-128. doi:10.1016/j.drugpo.2018.08.007
- Park JN, Frankel S, Morris M, et al. Evaluation of fentanyl test strip distribution in two Mid-Atlantic syringe services programs. Int J Drug Policy. 2021;94:103196. doi:10.1016/j.drugpo.2021.103196
- Strathdee SA, Celentano DD, Shah N, et al. Needle-exchange attendance and health care utilization promote entry into detoxification. J Urban Health. 1999;76(4):448-460. doi:10.1007/BF02351502
- Havens JR, Latkin CA, Pu M, et al. Predictors of opiate agonist treatment retention among injection drug users referred from a needle exchange program. J Subst Abuse Treat. 2009;36(3):306-312. doi:10.1016/j.jsat.2008.07.002
- Frost MC, Williams EC, Kingston S, Banta-Green CJ. Interest in Getting Help to Reduce or Stop Substance Use Among Syringe Exchange Clients Who Use Opioids. J Addict Med. 2018;12(6):428-434. doi:10.1097/ADM.0000000000000426
- Hagan H, McGough JP, Thiede H, Hopkins S, Duchin J, Alexander ER. Reduced injection frequency and increased entry and retention in drug treatment associated with needle-exchange participation in Seattle drug injectors. J Subst Abuse Treat. 2000;19(3):247-252.
- Doherty MC, Junge B, Rathouz P, Garfein RS, Riley E, Vlahov D. The effect of a needle exchange program on numbers of discarded needles: a 2-year follow-up. Am J Public Health. 2000;90(6):936-939.
- de Montigny L, Vernez Moudon A, Leigh B, Kim SY, Young K. Assessing a drop box programme: a spatial analysis of discarded needles. Int J Drug Policy. 2010;21(3):208-214. doi:10.1016/j.drugpo.2009.07.003
- Marx MA, Crape B, Brookmeyer RS, et al. Trends in crime and the introduction of a needle exchange program. Am J Public Health. 2000;90(12):1933-1936.
- Galea S, Ahern J, Fuller C, Freudenberg N, Vlahov D. Needle exchange programs and experience of violence in an inner city neighborhood. J Acquir Immune Defic Syndr. 2001;28(3):282-288. doi:10.1097/00042560-200111010-00014
- Davidson PJ, Lambdin BH, Browne EN, Wenger LD, Kral AH. Impact of an unsanctioned safe consumption site on criminal activity, 2010-2019. Drug Alcohol Depend. 2021;220:108521. doi:10.1016/j.drugalcdep.2021.108521
- Peters PJ, Pontones P, Hoover KW, et al. HIV Infection Linked to Injection Use of Oxymorphone in Indiana, 2014–2015. New England Journal of Medicine. 2016;375(3):229-239. doi:10.1056/NEJMoa1515195
- Cranston K, Alpren C, John B, et al. Notes from the Field: HIV Diagnoses Among Persons Who Inject Drugs — Northeastern Massachusetts, 2015–2018. MMWR Morb Mortal Wkly Rep. 2019;68. doi:10.15585/mmwr.mm6810a6
- Atkins A, McClung RP, Kilkenny M, et al. Notes from the Field: Outbreak of Human Immunodeficiency Virus Infection Among Persons Who Inject Drugs — Cabell County, West Virginia, 2018–2019. MMWR Morb Mortal Wkly Rep. 2020;69(16):499-500. doi:10.15585/mmwr.mm6916a2
- Schackman BR, Fleishman JA, Su AE, et al. The Lifetime Medical Cost Savings From Preventing HIV in the United States. Medical Care. 2015;53(4):293-301. doi:10.1097/MLR.0000000000000308
- Singer JA, Heimowitz S. Drug Paraphernalia Laws Undermine Harm Reduction. Cato Institute. Published June 7, 2022. Accessed June 14, 2022. https://www.cato.org/policy-analysis/drug-paraphernalia-laws-undermine-harm-reduction-reduce-overdoses-disease-states
- Green TC, Martin EG, Bowman SE, Mann MR, Beletsky L. Life After the Ban: An Assessment of US Syringe Exchange Programs’ Attitudes About and Early Experiences With Federal Funding. Am J Public Health. 2012;102(5):e9-e16. doi:10.2105/AJPH.2011.300595
- Javed J, Burk K, Facente S, Pegram L, Ali A, Asher A. Syringe Services Programs: A Technical Package of Effective Strategies and Approaches for Planning, Design, and Implementation. US Department of Health and Human Services, National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention, Centers for Disease, Control and Prevention; 2020. Accessed September 5, 2022. https://www.cdc.gov/ssp/docs/SSP-Technical-Package.pdf
- Sherman SG, Purchase D. Point Defiance: a case study of the United States’ first public needle exchange in Tacoma, Washington. Int J Drug Policy. 2001;12(1):45-57. doi:10.1016/s0955-3959(00)00074-8
- Bluthenthal RN, Anderson R, Flynn NM, Kral AH. Higher syringe coverage is associated with lower odds of HIV risk and does not increase unsafe syringe disposal among syringe exchange program clients. Drug Alcohol Depend. 2007;89(2-3):214-222. doi:10.1016/j.drugalcdep.2006.12.035
- Kral AH, Anderson R, Flynn NM, Bluthenthal RN. Injection risk behaviors among clients of syringe exchange programs with different syringe dispensation policies. J Acquir Immune Defic Syndr. 2004;37(2):1307-1312.
- Hyshka E, Strathdee S, Wood E, Kerr T. Needle Exchange and the HIV Epidemic in Vancouver: Lessons Learned from 15 years of research. Int J Drug Policy. 2012;23(4):261-270. doi:10.1016/j.drugpo.2012.03.006
- Barocas JA, Baker L, Hull SJ, Stokes S, Westergaard RP. High uptake of naloxone-based overdose prevention training among previously incarcerated syringe-exchange program participants. Drug Alcohol Depend. 2015;154:283-286. doi:10.1016/j.drugalcdep.2015.06.023
- U.S. Substance Abuse and Mental Health Services Administration. Harm Reduction Grant Program. SAMHSA. Published 2022. Accessed September 4, 2022. https://www.samhsa.gov/grants/grant-announcements/sp-22-001
- Wang Y, Yu M, Yan B, Martin P, Robertson B. Effects of Food on the Bioavailability of Amphetamine in Healthy Adults After Administration of SHP465 Mixed Amphetamine Salts Extended-Release Capsules. Drugs R D. 2019;19(2):167-175. doi:10.1007/s40268-019-0267-y
- Ronsley C, Nolan S, Knight R, et al. Treatment of stimulant use disorder: A systematic review of reviews. PLoS One. 2020;15(6):e0234809. doi:10.1371/journal.pone.0234809
- Laing MK, Tupper KW, Fairbairn N. Drug checking as a potential strategic overdose response in the fentanyl era. International Journal of Drug Policy. 2018;62:59-66.
- Oliva EM, Bounthavong M. Commentary on Rege et al. (2018): Naloxone reports to US poison centers highlight overdose prevention opportunities. Addiction. 2018;113(12):2316-2317.
- Ibragimov U, Cooper KE, Batty E, et al. Factors that influence enrollment in syringe services programs in rural areas: a qualitative study among program clients in Appalachian Kentucky. Harm Reduction Journal. 2021;18(1):68. doi:10.1186/s12954-021-00518-z
- U.S. Centers for Disease Control and Prevention. Tribal Syringe Services Program Helps Reduce Harm from Injection Drug Use. Public Health Professionals Gateway. Published 2020. Accessed October 29, 2021. https://www.cdc.gov/publichealthgateway/field-notes/2020/cherokee-hepatitis.html
- Sonoran Prevention Works. Our Story. Sonoran Prevention Works. Published 2022. Accessed August 7, 2022. https://spwaz.org/about/
- Prevention Point Philadelphia. STEP. Prevention Point. Published 2020. Accessed June 8, 2022. https://ppponline.org/node/125/step
- Knopf T. Mobile Syringe Exchange Serves People Where They Are. North Carolina Health News. Published August 10, 2017. Accessed June 14, 2022. http://www.northcarolinahealthnews.org/2017/08/10/mobile-syringe-exchange-serves-people-where-they-are/
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